Case Report ARareCaseofPoplitealVenousAneurysmdownloads.hindawi.com/journals/crim/2010/579256.pdf · Case Reports in Medicine 3 1 (a) (b) 1 (c) Figure 2: Angio-ComputedTomography

Hindawi Publishing CorporationCase Reports in MedicineVolume 2010, Article ID 579256, 4 pagesdoi:10.1155/2010/579256

Case Report

A Rare Case of Popliteal Venous Aneurysm

Roberto Fiori, Roberto Chiappa, Eleonora Gaspari, and Giovanni Simonetti

Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiation Therapy,University Hospital “Tor Vergata”, 81 Oxford Street, 00133 Rome, Italy

Correspondence should be addressed to Eleonora Gaspari, [email protected]

Received 14 October 2009; Accepted 1 January 2010

Academic Editor: Arduino A. Mangoni

Copyright © 2010 Roberto Fiori et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

We report a case of a 21-year-old man with a popliteal venous aneurysm of the left popliteal fossa, with local symptoms and painduring palpation. Early diagnosis is fundamental in order to prevent the thromboembolic events or other major complications.Duplex scanning, Computed Tomography scanning, and Magnetic Resonance imaging are considered to be important non-invasive diagnostic methods for the diagnosis of PVA. The Angio Computed Tomography acquisition confirmed a 36 mm× 17 mmoval mass in the left popliteal fossa continuous with the popliteal veins. This lesion had presented contrast enhancement only indelayed acquisition (180 sec) and so appeared to be a true venous aneurysm and no arterial. The PVA was repaired surgically viaa posterior approach to the popliteal fossa. A 4 × 2 aneurysm was identified. In the same time open tangential aneurysmectomyand lateral vein reconstruction were realised. This case is interesting because the Angio Computed Tomography study, in delayedacquisition, has allowed a correct diagnostic assessment of PVA and the surgical treatment.

1. Introduction

Popliteal venous aneurysms (PVAs) may cause fatal com-plications (e.g., pulmonary embolism and other throm-boembolic episodes) [1, 2] if they remain undiagnosed oruntreated. These lesions may have more or less symptomaticmanifestation above all in females and more frequently inpeople over 40 years [3–6]. We report a case of a 21-year-oldman with a popliteal venous aneurysm of the left poplitealfossa, with local symptoms and pain during palpation.

2. Case Report

A 21-year-old male footballer has presented, for a fewmonths after trauma a local discomfort in particular in theleft popliteal fossa during palpation and usual daily activities.

Physical examination was negative for the presence of asoft mass in the upper part of the popliteal left fossa withoutlocal signs of inflammation. Instead was positive for the painin the front part of the left knee during palpation. There wasno evidence of clinical signs of peripheral arterial angiopathy.Chest and abdomen examination, arterial blood pressure,

chest X-ray, oxygen saturation, and electrocardiogram werenormal.

Duplex scanning, Computed Tomography scanning, andMagnetic Resonance imaging (MRI) are considered to beimportant non-invasive diagnostic methods for the diagnosisof PVA.

Magnetic Resonance imaging (MRI) without contrastmedia demonstrated a 4 × 2 cm oval formation withdishomogeneous hyperintensity on T1-and T2-weightedsequence in the left popliteal fossa adjacent to the vesselssuspected for a blood lesion (Figure 1).

Then the color-Doppler ultrasonography (US-CD) wasperformed to identify the true origins of this lesion. Thisexamination demonstrated only a mixed echogenicity massin the left popliteal fossa with no evidence of arterial orvenous nature.

Subsequently this mass was evaluated with Angio-Computed Tomography (ACT) using a computed tomog-raphy scanner (Highspeed Advantage, GE Medical SystemMilwaukee, WI, USA).

Images were acquired without and with contrast mediaintravenously (a single bolus of 120 cc with a flow rate of3.5 ml/s of nonionic contrast medium via an antecubital

2 Case Reports in Medicine

(a) (b)

Figure 1: Magnetic Resonance (MRI), SE T1 Dual axial (a), SE T2 FFE sagittal (b) showing a 4 cm oval-shaped formation withdishomogeneous hyperintensity in the left popliteal fossa adjacent to the vessels.

venous access) and a scan was obtained with three phasesfrom the injection of contrast media.

Every data acquired were transferred to an AdvantageWindows workstation (GE Advantage) and reconstruedusing maximal intensity projection (MIP) and volumerendering (VR) technique.

The ACT acquisition confirmed a 36 mm × 17 mm ovalmass in the left popliteal fossa continuous with the poplitealveins. This lesion had presented contrast enhancement onlyin delayed acquisition (180 sec) and so appeared to be a truevenous aneurysm(Figures 2 and 3).

The PVA was repaired surgically via a posterior approachto the popliteal fossa. A 4× 2 cm aneurysm was identified. Inthe same time open tangential aneurysmectomy and lateralvein reconstruction were realised (Figure 4).

A histopathologic examination revealed an aneurysmvenous wall with none evidence of inflammatory or degen-erative signs.

The patient was given warfarin for anticoagulation andwas discharged on the 3th postoperative day. Two monthspostoperatively, the patient’s symptoms were improved; therepetition of venous duplex scanning showed patency of therepaired popliteal vein without venous thrombosis.

Elastic stockings were suggested for support, and dailyaspirin was recommended for prophylaxis against thrombo-sis. The patient was able to resume normal activities.

3. Discussion

Popliteal venous aneurysms are uncommon and not clin-ically important in most cases. However they can leadto severe complications including deep-vein thrombosis,pulmonary embolism, and death [7, 8].

The etiology of venous aneurismal remains unknown butcongenital factors, inflammation, trauma, or degenerativechanges have been proposed [9]. Probably in this caserepeated episodes of microtrauma related to the footballercontributed to the development of the venous aneurysm.

Asymptomatic incidental detection, local lower extrem-ity symptoms, or embolic pulmonary episodes may representdifferent aspects of manifestation of the same condition [1].

Most popliteal venous aneurysms are showed withpulmonary embolism (24%) or chronic venous disease (76%limb swelling, postthrombotic symptoms) [10]; but usuallythey are impalpable on clinical examination, although pre-sentation with a popliteal mass is not uncommon (26%)[11].

In this case the ACT study has permitted a correct diag-nosis assessment of PVA. This lesion had presented contrast-enhancement only in delayed acquisition (180 seconds) andit had demonstrated that this aneurysm was venous and notarterial.

Other differential diagnosis of PVA could be the Baker’scyst and tibiofibular cysts. These lesions are different insite and morphology, but the diagnosis is easy with theUltrasonography and MRI.

Baker’s cyst is a persistent joint fluid effusion (synovial)that can be localized in the back of the knee. It can becaused, more frequently in adults, by posterior herniationof the knee joint capsule. Cysts in the proximal tibiofibularjoint are uncommon, and they have a similar manifestation.Their clinical diagnosis is difficult. In both cases the USexamination shows an ipo-echogenicity mass and the MRIdemonstrates an oval mass hypointensity on T1-weightedsequence and hyperintensity on T2-weighted sequence.

Surgical options in the treatment of symptomatic andasymptomatic cases include tangential aneurysmectomy

Case Reports in Medicine 3

1

(a)

1

(b)

1

(c)

Figure 2: Angio-Computed Tomography (ACT) was obtained with three phases: arterious (a), venous (b), and delayed (c) from the injectionof contrast media. The ACT acquisition confirmed a 36 mm × 17 mm oval mass in the left popliteal fossa. This lesion presented contrastenhancement only in delayed acquisition (c) and so appeared to be a true venous aneurysm.

(a) (b)

Figure 3: Angio-Computed Tomography (ACT) scan reconstruction using maximal intensity projection (MIP), volume rendering (VR)technique, and 3D showing the popliteal venous aneurysm in the left popliteal fossa.

4 Case Reports in Medicine

Figure 4: Surgical image showing the popliteal venous aneurysm.

with lateral venorrhaphy, resection with end-to-end anasto-mosis, resection with interposition graft, or ligation of theproximal and distal vein. Early patency rates are encouraging,with no reports of recurrent pulmonary embolism followingsurgical repair, although the long-term results of surgery areunknown [12].

4. Conclusion

Early diagnosis is fundamental in order to prevent the throm-boembolic events or other major complications. This caseis interesting because the ACT study, in delayed acquisition,has allowed a correct diagnostic assessment of PVA and thesurgical treatment.

References

[1] L. J. Herrera, J. W. Davis, and J. J. Livesay, “Popliteal veinaneurysm presenting as a popliteal mass,” Texas Heart InstituteJournal, vol. 33, no. 2, pp. 246–248, 2006.

[2] J. R. Dahl, T. A. Freed, and M. F. Burke, “Popliteal veinaneurysm with recurrent pulmonary thromboembolic,” TheJournal of the American Medical Association, vol. 236, pp.2531–2532, 1976.

[3] P. Quandalle, A. Saudemont, J. P. Chambon, and A. Wurtz,“Aneurysm of the deep veins of the legs. Apropos of a caseinvolving a vein in the calf,” Journal de Chirurgie, vol. 126, no.11, pp. 586–590, 1989.

[4] J. Chahlaoui, M. Julien, and P. Nadeau, “Popliteal venousaneurysm: a source of pulmonary embolism,” AmericanJournal of Roentgenology, vol. 136, no. 2, pp. 415–416, 1981.

[5] C. R. Jack Jr., R. Sharma, and R. B. Vemuri, “Popliteal venousaneurysm as a source of pulmonary emboli in a male: casereport,” Angiology, vol. 35, no. 1, pp. 54–57, 1984.

[6] G. J. Ross, L. Violi, L. W. Barber, and I. Vujic, “Popliteal venousaneurysm,” Radiology, vol. 168, no. 3, pp. 721–722, 1988.

[7] L. H. Greenwood, J. M. Yrizarry, and J. W. Hallett Jr.,“Peripheral venous aneurysms with recurrent pulmonaryembolism: report of a case and review of the literature,”CardioVascular and Interventional Radiology, vol. 5, no. 1, pp.43–45, 1982.

[8] G. D. Grice III, R. B. Smith III, P. H. Robinson, and J.M. Rheudasil, “Primary popliteal venous aneurysm with

recurrent pulmonary emboli,” Journal of Vascular Surgery, vol.12, no. 3, pp. 316–318, 1990.

[9] S. G. Friedman, K. V. Krishnasastry, W. Doscher, and S. L.Deckoff, “Primary venous aneurysms,” Surgery, vol. 108, no.1, pp. 92–95, 1990.

[10] C. Sessa, P. Nicolini, M. Perrin, I. Farah, J.-L. Magne, and H.Guidicelli, “Management of symptomatic and asymptomaticpopliteal venous aneurysms: a retrospective analysis of 25patients and review of the literature,” Journal of VascularSurgery, vol. 32, no. 5, pp. 902–912, 2000.

[11] D. Bergqvist, M. Bjorck, and C. Ljungman, “Popliteal venousaneurysm—a systematic review,” World Journal of Surgery, vol.30, no. 3, pp. 273–279, 2006.

[12] J. J. Gallagher and J. H. Hageman, “Popliteal vein aneurysmcausing pulmonary embolus,” Archives of Surgery, vol. 120, no.10, pp. 1173–1175, 1985.

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Case Report ARareCaseofPoplitealVenousAneurysmdownloads.hindawi.com/journals/crim/2010/579256.pdf · Case Reports in Medicine 3 1 (a) (b) 1 (c) Figure 2: Angio-ComputedTomography